04090200 CITY OF CUPERTINO € `' ' �
BUILDING DIVISION PERMIT CONTRAC=TOR INFORMATION ,
BUILDING ADDRE55: PERMIT NO.
STEVE KIM 04090200
WNER'SNAoj ,qrE: PERMOTISUEDATE
aNE: SANITAcTPVT?. KTM_ 203 6/20190 FOREST- AV S RY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 = o
�zZ LICENSED CONTRACTOR'S DECLARATION
Job Description
T ion 7 affirm that land of
ft Bd under provisions of Chaps. 9(commencing P
2� within ll Come and 7IX cfaf Diviaion3of WC Buvnuiand hofessiom Code.erW my license is
License Class L;e.g TERMITE REPAIR (BATH/KITCHEN/REMOVE CHIMNEY)
4;:p Da¢ Contractor
7W ARCHITECTS DECLARATION
?wU Iundcrsund myflansahall Mused as puhlic memos START JOB WITHOUT PERMIT/DOUBLE BPERMFEE PAID
GC Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from Inc Contractor's License Law for the
O D following mason.(Section](131.5,Business and Professions Code:Any city Or county
Q which requires a permit to construct,alma.improve,dcmulish,or repair any someone
prior m its issuance.also rcquires the applicant for such permit m file a signed statement
on that he is licensed pursuamm the pmvisiom of the Contractor's Licc.Law(Charon,9 Sq%Fl. Floor.'e'.5�rea Valuation
�Fa (commencing with Section 7M)of Division 3 of the Business and Professions Code)or ;L 1, �� 1v 17 r]ta.y.�
Nat W H exempt thcrttrom and Ne basis for the alleged exemption.Any violation of 5 1 t7 Ir"�f ` nw.�
Section 7031.5 by any applicant for a permit subjects the applicant a civil family of a
not more than five hundred dollars(S500).
AIjN'Number t� � ecupancy,Type
❑I,nowner of the pmpeny,Ormy cmployca with wages as Heir sole compensation, // 1 f I
willdo the work.andNmwnurt is notin¢nded or oRcred forsale(Sec.]014.Busiess 0, 2 00 1R,ygrD1I peC Ui y 10
s
and Professions Code:The Commodes License Law docs not apply In an owner of
o
property who buildsor impmvthemon.and who dassuch work himselfor through his TUU!
own employees,provided that such Improvements are not intended orottered for sale.If.
however.the building or improvement is sold within one year of complcuen,the moor-
builder will have the burden of proving Nn M did not build or improve for Imposter of
sale.).
El I,as Owner of tine progeny,am exclusively enamoring with licensed convectors to
convect the project(Sec.7014.Business and Pfofessions Code:)The Connectors Li.
cane law docs not apply to an Owner of property who Wilds or improves Merton,and
who contracts for such projects with a conwnm(s)licansed pursuant N the Conuactoes
License Law.
acmpt under Ser. .B&P C f Ins axon
2d
WORKER'S COMPENSATION DECLARATI
1 hereby aRnm under penalty of perjury oro of Ne following declarations: -
1 have mrd will maintain a CeruBmm ofCmucnuo self-insure for WorkeesCOmpen-
ratipn,as provided for by Section 3700 of Ne Labor Code,for the peffasm.ce of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as requirod by Section
37W of Ne labor Code.for IW prornmanee of the work for which this permit is issued
My Workers Compensation Inaursna carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seehm need not bccomplemd if the permit is for one hundred dollars(SIM)
or less)
I certify Nat;n the performance of dm work Tor which this permit is issued,1 shall nut
employ any gory in any menner m omeyybjecuoun Workers Compensation'
laws of CalBE is Wtc � �r'vkgcY
Apple �_ T
NMCZQ'O APPLICANT:if.after making this Cenificare of Exemption,you should
become subjwt he the Workers Compensation previsions of the Labor Chile.you most
.,O fordw W comply with such provision or mea permit shall W darned rt
vnkcd.
Z= CONSTRUCTION LENDING AGENCY
[—i Ihereby affirm that them is a mnswctinn lending agency ler Ne pmrurmance of
(YNe work for which this permit is knead(Sec.3007,Civ.C.)
SA Lenin's Name
,0 Z Lender's Address
U 0 I cinify that 1 have road this application end sure Nat the aterve information is
ly correct.1 agree to comply with all city and county ordinances and state laws totaling in
DU building convection.and hereby euthorin ropmaenuthea of this city to corer upon Inc
W above-mentioned property,for inspection purposes.
Wo)agree N save,indemnify and kap honnless the City of Cupcnino against F' r%j liabilities,judgmcros.costs and exp'"".which may In any way aamc against said City
U Z s Permit.
APPLICeUNDERSTANDS Aof tvc grunting of ND ANTND WILL COMPLY WITH AL NON DINT Issued by: Date
SOURCE REGULATIONS. is /,a �d
/ Re-roofs
s'
alikeof App c.oContrrzmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WiII We applicant or future building occupant store or handle hmardous material
as defined by the'u no Municipal Code.Chapter 9.12,and IW Health and Safety
Co dc.Section 25532(-)] All roofs shall be inspected prior to any roofing material being installed.
❑Yce No
Will the applicant or furore building Oaopam sew equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardnn air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
p Yes
I have mad the hccrarZ materials requiremms underCharnwr 6.95 orthe Carrot.
rda HcalN&SafctyCade.Scctimu 25505.25533 and 2553-.l unMreand Natifthe,Wilding
does not currently have a Imam Nat it IS my resporuib;nty to notify tW mup an of Ne
wmm�tops et pdm Rtissuaneeora Cenifiealeor Oc p try. Signature of Applicant Date
I UD
a or ant mice. agent Data All roof coverings to be Class"B"or better